Swine flu, or Influenza A (H1N1) - what's in a name

It's quite comical really the games people play. In the past they were just quite happy to stick on country labels to the pandemics, because it was always someone else - Spanish flu, Asian flu, Hong Kong flu...etc.... now you can't do that anymore. The Mexican's object to it being called the Mexican flu, even though they are the epicentre. And no, you can't call it the American flu, even though that's where most of the flu is at the moment. No you can't call it the Swine flu, 'cos you will put people off eating pork and kill the pork industry.

So let's just call it the Influenza A (H1N1) flu.

Yay.

Tamiflu or shamiflu?

So the MOH has raised the alert once again, to Orange this time. Byt actually the disease doesn't seem to be that fatal outside of the Mexican epicentre. Hopefully it will remain that way, because there is really no way from stopping the infection from becoming a full blown pandemic.

But never fear, Tamiflu is here!!! MOH says we have stockpiled enough drug. All 1.15 million doses. Yay!

But frankly, how much faith are we able to put in that wonder drug?

Errr..... My personal opinion is .....not much. There is a lot of focus on Tamiflu, really, not because of it's efficacy but because we have precious in terms of alternatives to put our faith in, i.e. the man of steel isn't going to swoop down and save us all. We look to Tamiflu because the public needs to feel gahment is doing something. This is not just a Singapore phenomenon, but happening globally.

So what are the facts....?

H1N1 isn't a new virus. The swine flu H1N1 strain is new....but other H1N1 strains have been circulating the globe for some time. In the US, 98.5% of H1N1 strains are resistant to Tamiflu. For those whose statistics desert them in moments like these, essentially Tamiflu doesn't work against circulating H1N1 strains.

But then again it is possible the the latest swine flu H1N1 strain is relatively new and may in fact be sensitive still to Tamiflu. So what does Tamiflu do? Well...Tamiflu is what is called a neuramidase inhibitor. For it to be effecttive it has to be given very early. Earlier the better. Problem is....symptoms begin only a few days after the infection, so you have lost a couple of very precious days. So health care workers comfort themselves by saying must give within 24-48 hours of first symptoms. That's really 4-5 days after infection.

But what are the effects of Tamiflu...? Apparently not much...despite being 'effective' against the virus, Tamiflu when given early merely speeds recovery and shortens the disease by 30%, or 1.3 days. I leave that to you to figure out how effective it is.

Possibly it may save some lives, but don't expect miracles. But like they say...better than nothing, lor...!

AWARE and sexuality education

The AWARE nonsense has opened a can of worms. Recently we found out per courtesy of the cat fight that the Ministry of Education had outsourced sexuality education to AWARE!!

Errrmmm....why? Have they taken leave of their senses?!! I got nothing against the association per se, and they are free to do whatever they want to do...but for the MOE to outsource something so important to a organization with liberal gay-lesbian leanings?

I think the MOE has to tell us more than just provide vague motherhood statements about the suitability of the guidelines etc etc. Senior Minister of State S Iswaran was quoted as saying "GET your facts right on what is happening in Singapore schools when it comes to sex education, and do not base comments on 'innuendo or information received on the fly'." Well, he's absolutely right. But SMOS Iswaran, how to get the facts right if you don't tell us the full facts? What I think you should tell us SMOS Iswaran, are:

a] Who actually vets the contents? And I mean the full contents, not just the headings and vague motherhood statements.
b] How do you select the teachers of this 'sexuality education'? And what their sexual values and leanings are, especially with respect to homosexuality?
c] What is the MOE's stand on homosexuality education in schools? Please be specific, and no motherhood statements about "value-based decisions etc", whatever that is supposed to mean.

I think the public and all concerned parents have a right to know.

* Let me make my position very clear on this issue. I don't really care what people do in their own time and in their own lives. In the end they have to deal with their own God, gods, or lack of... And it's their own choice and decision. What I absolutely reject is the right of a small militant group of people who have chosen a certain variant path to dictate to the majority (school children, for God's sake!) that their choice should be the norm.

Swine flu - better safe than sorry

The MOH has raised the alert level from green to yellow, and the hospital environment is congested with long visitor queues, with fully decked out screening teams. But despite the congestion, to the hospital's credit, things are moving smoothly, albeit slowly. And to the public's credit, they have been very understanding and there have been few real complaints.

In my opinion the world has probably overreacted to the impending pandemic. In a week or so things will be clearer and we will know if this pandemic scare is just hysteria or a real danger to us all. Currently there have been no deaths outside Mexico, but that might change. For the moment it looks like the virus either rapid attenuates after initial infection, or that the deaths are just the tip of a very big iceberg, which really means the infection has a very low mortality.

Anyway, we'll find out soon. In any case, given the previous SARS experience, the MOH is wise to 'overreact', and it is better to be safe first than sorry later.

Keep safe.

So when does a pandemic become a pandemic?

Today the WHO uprated the swine flu alert to Level 4 which means it recognizes the ability of the infection to spread from human to human. This is a necessary step towards it becoming an established pandemic.

So what makes a pandemic a pandemic?

The word Pandemic is from two greek words which mean: 'pan' -all, and 'demos' - people. So a pandemic refers to all peoples. In infectious disease, a pandemic means an infection that spread among all people, implying a transnational or transgeographic spread. In practical terms a pandemic has first of all to be an infection. That there are homosexuals all round the world doesn't make it a pandemic. But HIV is a pandemic. Secondly, the infection is not limited to just one nation or one geographic location. In the case of the current swine flu, the infection is seen primarily in Mexico. The non-Mexican cases currently appear to originate from Mexico, hence the it has not really spread beyond Mexico. But the moment, Canada or the US, show cases that are spread locally, that would imply spread beyond Mexican borders. That would bring it closer to being called a pandemic.

Swine Flu - evolving pandemic - MOH Medalert

So here we are heading right into another pandemic. While we were distracted by the Avian Flu (H5N1), the dreaded Influenzavirus A strain has made its appearance in a fairly aggressively infectious disease fast spreading among humans in Mexico.

Swine Flu (Wikipedia)
Swine Flu (Center for Infectious Diseases)

Our Ministry of Health's Medalert for doctors here:

MH 34:03
25 April 2009
All Registered Medical Practitioners

MOH CIRCULAR 17/2009

ALERT: SWINE INFLUENZA A (H1N1)

In Mexico, as of 23 April 2009, 854 cases of severe atypical pneumonia have been reported, including 59 deaths. Several cases have been confirmed as swine Influenza A (H1N1). Those affected included healthcare workers and their family members with close contact. Most of the cases have occurred in central Mexico (especially Mexico City) but there have been cases in states along the U.S.-Mexico border. Schools and public institutions such as museums, libraries and theatres have been closed in Mexico City.

2 In the US, there have been a total of 8 laboratory confirmed cases of swine influenza (6 in Southern California and 2 in Texas). 6 cases had selflimited illness and 1 was hospitalized. No deaths have been reported. No recent exposure to pigs has been identified for any of the patients. In one case, there was a history of recent travel to Mexico.

3 Preliminary genetic analysis of the influenza viruses have identified them as swine Influenza A (H1N1 viruses), containing genetic segments from swine influenza viruses from North America, Europe and Asia, avian influenza viruses from North America, and human influenza viruses. This particular genetic combination of swine influenza has not been recognized previously. The US CDC laboratory has identified the same strain of swine Influenza A (H1N1) in specimens from patients with respiratory disease in Mexico as that identified in the US cases.

4 These reports raise concerns about human-to-human spread of a novel influenza virus.

Clinical Symptoms
5 The symptoms of swine influenza in humans are similar to human seasonal influenza. These include fever, sore throat, cough and rhinorrhoea. Some patients may also complain of nausea, vomiting, diarrhoea, myalgia, and headache. The disease may be complicated by pneumonia. Most of the cases have been in younger adults but older adults have not been spared.

Laboratory Investigation
6 The diagnosis of swine influenza may be confirmed by laboratory identification and sub-typing of the virus in naso-pharnygeal swabs obtained from suspected cases.

Treatment and Vaccination
7 It is likely that the current seasonal influenza vaccine will not provide protection from this new subtype of influenza A. The viruses in the US patients have demonstrated antiviral resistance to amantadine and rimantadine. However, they are susceptible to oseltamivir (Tamiflu®) and zanamivir (Relenza®).

REQUIRED ACTION
8 Clinicians should observe strict infection control precautions when handling patients:
a) Presenting with influenza-like symptoms (fever, cough, sore throat, rhinorrhoea); AND
b) Have a history of travel to affected areas (i.e. Mexico, and the states of California and Texas in the United States) in the 7 days prior to the onset of symptoms; OR have been in contact with ill persons who had a history of travel to these areas in the 7 days prior to the onset of symptoms.

9 Any patient who meets the case definition in Paragraph 8 should be referred immediately to the Emergency Medicine Department at Tan Tock Seng Hospital. Medical practitioners should arrange for these patients to be transferred by ambulance by calling the dedicated ambulance service at 65860237 (available 24 hours).

10 The Ministry of Health should also be notified immediately of suspected cases. Please contact the Communicable Diseases Division at 98171463 (available 24 hours). MOH will inform the notifying doctor of the need for contact tracing and prophylaxis for close contacts of the case once the diagnosis has been established.

ADVICE TO PATIENTS
11 Physicians should advise family members and other close contacts of suspected cases to be vigilant for early symptoms of influenza, and to seek medical advice as early as possible if unwell.

FURTHER INFORMATION
12 An FAQ sheet for patients is attached at Annex 1.

13 For updates on this evolving situation, please refer to the MOH website
www.moh.gov.sg

14 For further clarifications of this circular, please email
moh_info@moh.gov.sg.

PROF K SATKU
DIRECTOR OF MEDICAL SERVICES



FAQS ON SWINE FLU
ANNEX 1

1. What is Swine Flu (Swine Influenza)?
Swine flu is a respiratory disease affecting pigs that is caused by type A influenza virus. Swine influenza viruses may circulate among swine throughout the year, but most outbreaks occur during the late fall and winter months similar to influenza outbreaks in humans. It causes high levels of illness but low death rates in pigs.

2. Does Swine Flu affect humans?
Swine flu viruses that cause disease in pigs very rarely affect humans. However, sporadic human infections with swine flu have occurred. Most commonly, these cases occur in persons with direct exposure to pigs but there have also been documented cases of human-to-human spread of swine flu.

3. How does Swine Flu spread to humans?
Swine flu spreads to humans mainly through contact with infected pigs, which shed the virus in their saliva, nasal secretions and faeces. Limited human-to-human transmission can also occur in the same way as seasonal flu occurs in people.

4. Can people catch Swine Flu from eating pork?
There is currently no evidence to suggest that swine flu can be transmitted to humans from eating pork or pork products that have been thoroughly cooked.

5. What are the symptoms of Swine Flu in humans?
The symptoms of swine flu in people are expected to be similar to the symptoms of regular human seasonal influenza. An early symptom is high fever, and this is followed by cough, sore throat, runny nose, and sometimes breathlessness a few days later.

6. How can human infections with swine flu be diagnosed?
To diagnose swine flu, a respiratory specimen would generally need to be collected within the first 4 to 5 days of illness (when an infected person is most likely to be shedding the virus). However, some persons, especially children may shed the virus for 10 days or longer.

7. What medications are available to treat swine flu infection in humans?
There are four different antiviral drugs that are licensed for use in Singapore for the treatment of influenza: amantadine, rimantadine, oseltamivir and zanamivir. While most swine flu viruses have been susceptible to all four drugs, the most recent swine flu viruses isolated from humans are resistant to amantadine and rimantadine. At this
time, the US CDC recommends the use of oseltamivir (Tamiflu®) or zanamivir (Relenza®) for the treatment and/or prevention of infection with swine flu viruses.

8. Are there any cases of Swine Flu in Singapore?
To date, there have been no human cases of swine flu detected in Singapore.

9. Is there any cause for alarm in Singapore?
No human swine flu cases have been reported in Singapore. MOH is monitoring the situation closely and will update the public should the situation change.

10. What is MOH doing to ensure that the disease is not
transmitted here?
MOH maintains a comprehensive and well established disease surveillance system for the early detection of human cases of novel influenzas such as swine flu. In addition, MOH has sent a medical alert to all medical practitioners and staff in hospitals, national centres, private medical clinics and polyclinics to update them on the outbreak of swine flu in the USA and Mexico and to advise them to be vigilant for any suspect cases. When the situation warrants, MOH will step up public health measures e.g. quarantine of contacts, issue public health advisories, and work with other government agencies to screen visitors at our border checkpoints. Further, MOH has an influenza pandemic preparedness plan in response to a pandemic situation.

11. Is it safe to visit countries with cases of Swine Flu and will I be quarantined when I return? What travel precautions should I take?
There are currently no travel restrictions or quarantine advised by the World Health Organisation for swine flu. If you intend to travel to areas which have cases of swine flu (currently – Southern California and Texas in the United States; and Mexico), you should take note of the following measures to minimize your risk of acquiring swine flu:

• Avoid contact with persons with symptoms of influenza
• Avoid crowded areas and maintain good ventilation.
• Observe good personal and environmental hygiene. Wash hands thoroughly with soap and water frequently and when they are contaminated by respiratory secretions e.g. after sneezing.
• Maintain good body resistance through a balanced diet, regular exercise, having adequate rest, reducing stress and not smoking.

12. What should I do if I suspect I have swine flu after returning to Singapore?
You should consult your doctor as soon as possible and inform your doctor if you have symptoms of swine flu and had recently travelled to areas which have cases of swine flu (currently – Southern California and Texas in the United States; and Mexico).

13. What should I do if I fall ill overseas?
You should consult a local doctor as soon as possible and refrain from traveling until you are certified fit by the doctor.

14. Does influenza vaccination help in preventing Swine Flu?
Vaccines are available to be given to pigs to prevent swine influenza. There is no vaccine to protect humans from swine flu. The seasonal influenza vaccine is unlikely to protect against H1N1 swine flu viruses.

15. Is it safe to come into contact with live pigs in nature reserves and the wildlife reserves?
So far, there are no known cases of swine flu in Singapore. However, proper hygiene practices, such as washing of hands after contact with animals including pigs, should be maintained.

Separation of conjoint twins - where are our medical ethicists when you need them?

Minister of Health Khaw Boon Wan has taken an important public position (today's ST) on the past attempts and present intent to separate conjoint twins.

"THREE of the four twins joined at the head who were separated in operations here are dead, and the fourth is not in good shape.

Given this track record and the similarly dismal results overseas, Health Minister Khaw Boon Wan on Sunday suggested that doctors reconsider plans to separate yet another pair of such conjoined twins.
Indian twins Vani and Veena, five, will go under the knife at East Shore Hospital in August if the medical team involved decides to proceed with the operation.

Neurosurgeon Keith Goh, who was involved in the marathon operations here to separate the two earlier sets of twins joined at the head, has been asked by the state government of Andhra Pradesh in India to carry out the surgery.
Speaking to reporters on Sunday at a grassroots event, Mr Khaw said that doctors would likely end up harming the patients and should not attempt such operations.

He said: 'Surgeons, in some instances, have to pick one twin to die to save the other. Even those who survive would often be left with brain damage. So, to what extent is this quality of life?'

The previous surgical attempts have left many doctors and ethicists dumfounded. To many, they were mainly attempts to do heroic operations for no other reason than self glorification. The only people who would truly benefit from the operations were the surgical teams and the institutions involved.

So Mininister Khaw should be congratulated for speaking out against it.

But where were our local medical ethicists when you needed them? And where was the Singapore Medical Council? Why didn't they have an opinion about the surgery?

What worries me also is the fact that the past surgery had been vetted and approved by the hospital ethics committee. One could question how objective and independent they were in coming to their decision. Or were they functioning more as advocates for the surgical team?

The workings of institutional ethics committees need to be seriously audited so that the public can be confident that they will independently act in the public's interest and not just pay lip service to ethical standards, while glancing at the hospital's bottom line. These processes will have to come under greater scrutiny if we are to go down the organ trading road. So much will hinge upon our ability to do things ethically.

AWARE? Quo Vadis?

Paul Jacobs, Dy Political Editor of Straits Times, wrote a pretty balanced editorial on the issue. I can't reproduce it here, so I suggest you go read for yourself. It's on pg A2 of today's issue.

from My Sketchbook

The Singapore Integrated Resort (IR) - Collateral damage?

As the building of the Integrated Resort (IR) progresses towards completion, the newly created Casino Regulatory Authority (CRA) is starting to make its presence known. In today's Straits Times, the CRA revealed how they will 'protect' gamblers and society by following a hybrid approach: The statutory board will have two arms - one dedicated mainly to the task of keeping bad hats out, the other to prevent Singaporeans from gambling beyond their means.

I am sure the CRA will do its work well....as well as any other regulatory authority in Singapore.

What many people have concerns about are the issues that are not so directly related to the casino itself. Perhaps you can control the gambling and the organized crime. But what about the other stuff like prostitution and alcohol related problems? Even without the IR, the police already seem to be unable (or even unwilling, some would say), to manage the burgeoning problems related to prostitution and binge drinking among our young.

What hope is there for us once the IR and casino dominate our social landscape?

Indian rojak mass poisoning timeline...

Well, some light is starting to be shed on the sequence of events related to the Indian Rojak Mass Poisoning incident.

What I have pieced together thus far is as follows......

Poisoning began about Thursday. Symptoms appeared Thursday evening and patients start to appear at GP clinics and CGH in the evening. MOH was informed and investigations begin. Stall was shut down on Saturday morning.

I think MOH/NEA did as well as they could....The question is...'Was it enough?'

What troubles me is that in the sequence of events, there was almost 48 hours between first exposure to the poisoning and eventual shut down and isolation of the stall. There was actually one full day (Friday) of unnecessary exposure allowed after the poisoning was first recognized before the stall was shut down. It is 'fortunate' that this was just a food poisoning (albeit affecting 154 people and causing 2 deaths). Perhaps not so fortunate for at least the one lady who died because she was poisoned on Friday.

I am not an expert of the management of mass poisonings or bio-terrorism, but it seems to my little mole brain, that there might have been too long a lag between the start of the poisoning and definitive action taken to isolate and contain the poison. It was a good thing it wasn't a very infectious incident. If it had been an actual bio-terrorist event, I wonder if this amount of time delay would actually be considered acceptable.

I think MOH/NEA need to go back and relook their proceures and timelines. All those exercises and drills for events like this might not be very indicative of our national preparedness, when we take so long to respond to a real mass poisoning situation like this.

Condolences to Richard Stanley's family - question for Mt Elizabeth - was this an avoidable hospital infection??

DBS CEO Richard Stanley passed away yesterday. My heartfelt condolences to his family. It's never ever easy to lose someone, a loved one, at the prime of his life, and in such a sudden unexpected manner.

Unexpected? Yeah... though he had leukemia, the disease for a large part can be managed reasonably well. He didn't die of the leukemia .... it should be recognized that he died of an unexpected hospital infection.

Acute Myelogenous Leukemia (Wikipedia)
Acute Myelogenous Leukemia (Leukemia-net.org)

In sharing in the family's grief, we must not neglect to ask the crucially important question .... one that the family in their moment of grief may be too 'pai seh' to ask...:

Was this death avoidable?

True, he had leukemia. And it's true that at this stage of the disease, he was prone to infections.... but was the infection really unavoidable? We had discussed hospital infections recently, and we had people protesting that hospitals have been doing all they could to control the problem, but Mt Elizabeth Hospital had been rather quiet.

So my question to Mt Elizabeth is this .... "Have you done all you could in reducing the risk of hospital infections...especially in a situation like this when the patient is ultra-susceptible to infections?"

It's a bit like in superclean Singapore, where we have a reputation of being able to eat off the pavements .... suddenly finding out that our famous food courts are little more than cess pits.
Quite malu, lah.

Vaccinating against cervical cancer - the problem with vaccines

Many people don't have a good appreciation of what vaccines can do, or ought to be doing.

Essentially vaccines are supposed to raise the immunity against a particular disease through the administration of an antigen associated with the disease, e.g. a virus antigen, so that the body can 'learn' to build up an immune response to it. The 'learning' creates an immunological memory which may last for a variable period of time.

The problem with vaccines, is that it is difficult to assess the true efficacy of a vaccine. At best one can only measure an antibody response. The assumption is that the better the antibody response, the more efficacious the vaccine. The follow-on assumption is that the presence of the antibody response 'protects' against the infection. In the case of cervical cancer, there are two principal assumptions...i] the raised antibody levels will completely protect against the papilloma virus infection at the cervix (not so easy to assume)....and ii] the protection against infection will be translated into protection against cervical cancer (even harder to assume). So essentially the true efficacy of the vaccine depends on two unproven (though logical) assumptions.

On the other side of the coin, vaccines are notably associated with a tendency to induce the body's immune system to turn upon itself and cause various diseases. This is uncommon but a real and recognizable phenomenon. The problem with the GSK vaccine is that it uses a novel way of stimulating the immune system that has not had the same history of safety as the Merck vaccine. The toxicity is not predictable and may not develop until many years after administration of the vaccine. Hence the risk is not easily assessed with short term (or often even with much longer term studies) clinical studies.

So for new vaccines such as the cervical cancer vaccines, neither clinical efficacy nor safety data can be fully relied upon without the need to make all kinds of assumptions and promises of success.

But the vaccine industry is a billion dollar one. It has been estimated that the annual market for each vaccine is about US$2 billion. Hence the market pressures for GSK and Merck to keep flogging their respective vaccines, and to encourage their use even beyond the approved indications (off-label use).

The public needs to be less gullible and a bit more guarded about overextended claims. The vaccines have potential to do a lot of good, but do be cautious. The added difficulty here is that our regulators (HSA) are not totally free from the pressures from the heavy muscled pharmaceutical industry. In this instance, one of the protagonists to this story is a company with a very strong industrial and academic presence in Singapore. I truly hope that the regulator is adequately provisioned to china-wall against industry interests and can continue to regulate wisely and independently.

Fingers and toes crossed.

Vaccinating against cervical cancer - medicolegal and ethical considerations of off-label use

There has been quite a bit of publicity about the issue of cervical cancer vaccinations, especially the application of this vaccine to older women. Today's Straits Times carried an article by Huang Huifern about this, and the forum page carried a letter from GSK Biologicals.

Here's my take on this.... and some words of caution ...

Firstly the public should be aware that regulatory authorities everywhere in the world approve medicines and their specific usage based on all available evidence submitted by the manufacturer with respect to efficacy and safety. The FDA does it, and so does the HSA in Singapore. As I understand it, based on existing evidence with respect to efficacy and safety, the approval in Singapore is only for females between 9-26 years. Now you may quibble about the quality of the decision, but for better or worse, the best available scientific evidence as evaluated by our regulatory authorities, is just that.

The approval does not mean it is illegal to use the vaccine in other situations. Such use is referred to as 'off-label' use of the drug. Both doctors and patients should however, be aware that such use is entirely at the risk appetite of the doctor who recommends it and the acceptance of the patient. No vaccine is entirely safe, and there are valid suspicions that the vaccines in question may produce serious though rare side effects.

A discussion of off-label use of drugs can be found here. While it applies largely to a US situation, it does give an insight into the ethics and medico-legal aspects of the off-label use. Some people regard it as a form of experimentation, since the use of the drug is being used in a manner that has not been approved or validated. As such, the off-label use of the drug should be reviewed by an ethics committee.

The medico-legal aspects also need to be considered. By using the vaccine in an unapproved context, the doctor exposes himself to a substantial medico-legal liability. If serious side effects occur and it can be shown that the doctor did not appropriately advise the patient of such risks or lack of efficacy data, he of course, opens himself to a law suit.

Lastly, the promotional activities of the manufacturer should be consistent with only the approved used of the medication. In the US, pharma companies have been taken to task for promoting the off-label use of drugs. I am not aware if there have been such precedences in Singapore, and would appreciate legal opinions about this here; but we should clearly be wary when manufacturers hype up their products so that it practically encourages and sanctions off-label use.

I hope this posting may provoke the legal eagles in cyberspace and regulators in HSA to respond in some way or other, and bring clarity to this issue.

Geylang Serai food poisoning - time to review our food safety procedures?

Just want to highlight a coincidental publication of a report about US Centers for Disease Control and Prevention comments on food safety.

"EFFORTS to improve food safety in the United States have 'plateaued,' exposing the need for an overhaul of the nation's food safety system, government health officials said on Thursday.

Despite work to improve food safety in recent years, the number of foodborne infections remained steady, with little change in the past few years, suggesting fundamental problems are not being solved.

'Progress has plateaued. This indicates to us that further measures are needed to prevent more foodborne illness,' Dr Robert Tauxe of the US Centers for Disease Control and Prevention told reporters in a telephone briefing."

The findings were outlined Thursday in a new CDC report on foodborne illness.

Following excerpt from CNN report.

"The FDA is working to keep consumers informed of the latest food recalls and food safety initiatives, and is hiring more scientists, investigators and inspectors as part of a wide-reaching effort to protect the food supply, the agency said. The report underscores the need for modernization of the system, an FDA official said.

"The FDA is embarking on an aggressive and proactive approach in protecting and enforcing the safety of the U.S. food supply," said Dr. David Acheson, associate commissioner for foods. "The FoodNet data indicates a need for a different approach to safeguard the food supply, and the FDA is committed to make the necessary changes to keep unsafe products out of the marketplace before they reach consumers."

Florida, California, North Carolina, Minnesota, Michigan and Massachusetts are working on a pilot program in which teams work with the FDA to react more quickly to potential threats to the food supply, Acheson said. Three additional states are expected to join the program this year.

The report also found that none of the Healthy People 2010 targets, set by the Department of Health and Human Services in 2000 to reduce foodborne illness and death by 2010, had been met last year.

"Lack of progress in reaching Healthy People 2010 goals for foodborne pathogens is not acceptable," said Nancy Donley, president of Safe Tables Our Priority (STOP). Her 6-year-old son Alex died after eating contaminated hamburger in 1993.

"It is clear that current food safety regulatory programs are not effective in reducing the toll of foodborne illness," she said. "We need the setting of strict microbial standards and improved government oversight and inspection of our food supply to ensure that other lives are not cut short and other families will not have to suffer as mine has."

So what now, MOH and NEA?

Geylang Serai food poisoning - the poor rats...

Well .... typically as in other kinds of hysteria, some irrationality creeps into the picture. Here my poor relatives (not that close, by the way - they are from the Muroidea family while us moles are from the Talpidae family) have become the scapegoats for everything tragic and negligent about the food poisoning. *sigh*

Fact is - rats usually carry disease related to salmonella and leptospirosis. They are just a convenient visible icon of a dirty environment. Killing rats without cleaning the environment will not save us. Cleaning the environment will make sure rats do not flourish. So this hysterical mass killing of rats is nothing more than a massive public relation exercise to demonstrate how much effort is going into cleaning the environment. Poor rats. Where is the SPCA when you need them?

Fact is the causative organism - Vibrio parahaemolyticus is a rather fragile thing that lives best in salty water. Hence it is carried in raw shellfish/seafood. It tends to be rather heat sensitive so a little bit of cooking (even just high warming above about 60C) will pretty much kill it. It does however produce a toxin that is more heat resistant.

This spate of food poison is caused by ingestion of lots of bacteria and toxin. Those who succumbed almost immediately after consumption of the rojak, suffered effects due to the toxin. Those who developed fever and other delayed symptoms of bacterial infection, clearly ingested lots of live bacteria.

How the contamination of food occured here remains a mystery. Sure...there must have been contamination of the rojak gravy by a raw seafood source. But how? The only seafood in Indian rojak are the deep fried prawn fritters. Not a likely source of poisoning I think.

The poor Pa'chik must be going through hell at the moment. What I fear is that he, like the rats, will become the scapegoat for this whole episode. This will create another unnecessary tragedy.

It now behoves the MOH and NEA to do a serious evaluation of their procedures and work quality. How much of this was due to systemic problems that created an environment where something like this was just waiting to happen. It is just far too easy and convenient to blame the last person holding the parcel when the bomb goes off.

What also puzzles me also is how come our management of food safety straddles 2 ministries? Do these ministries talk to each other or not? In the management of this mass food poisoning, how does reporting occur? Do people know how to report? And to which agency? Does the MOH tell the NEA when it receives reports? How quickly does this occur?

The examination of the response times between first symptoms and notification, and then notification and response is an extremely important indicator of how effective the 2 ministries have been. This is not a trivial matter to be swept under the carpet, but an vitally important consideration if we want to make sure of our national preparedness against biological or chemical terrorism.

Geylang Serai food poisoning - Vibrio parahaemolyticus

Big tragic wayang here.

For the scale of the epidemic and severity of infection, this is not just eating one or two infected shellfish, or contaminated food from a server with dirty hands. This is an infection resulting from a massive dose of live bacteria and toxins.

To my mind the only plausible source is the rojak gravy that functions primarily as a bacterial broth because it sits there on a warming stove for pretty much the whole day. Very happy bugs!

Question is how did the bugs get into the rojak gravy in the first place since it does not contain any kind of raw sea food products e.g. prawns or other shellfish? This is not a problem about dirty hands, or rats running in the longkangs. This is substantial contamination from raw seafood occuring after the rojak sauce has been initially cooked, and then incubated before serving.

How? Some things don't add up.

Hand Foot and Mouth Disease in Singapore - one week late

So the MOH alarm system has finally kicked in because the number of cases have soared and are just 12 short of numbers that would qualify it as an epidemic. This response is about a week late, I think. Last week the numbers were already in excess of the levels technically required to sound the alarm.

This is not just mindless rantings against a government agency. Simply, if we want to manage an epidemic, there must be early warning systems in place. The earlier you activate the warning, the more likely you will be able to manage the impending epidemic. That's what the threshhold triggers are there for. If you don't want to act when the trigger is actuated then what's the point of having the warning system?

Secondly if you seriously want to manage an epidemic you need to put in place other social and miscellaneous support sytems that will allow people to help you limit the infectivity of the disease. To my simple thinking, these would include:

a] giving the public guidelines as to what might be considered standard early diagnostic critera to act upon. By the time a child has blisters everywhere, he has already spread the infection.
b] giving the public some reasonable options should they suspect the child has HFMD. Currently most parents are loathe to consider that possibility because they have little option but to continue to send the child to school/care centre.
c] decent hospitable and friendly places where you can temporarily quarantine the infected kids, so that they don't spread the infection at home.

I know that even I, though reasonably knowledgeable about the problem, find it very difficult to figure out what to do in the event my child break outs. Can I? Should I? How?

The MOH should assist the public in formulating a proper action plan so that we can nip the epidemic early rather than keep wringing our hands every year as we watch the figures rise.

Human Organ Trade - a nuanced approach

A colleague once referred to Minister Khaw as the 'teflon man', referring to is ability to extricate himself from all kinds of sticky situations. I personally think that was being very unfair. I think Minister Khaw has perhaps been better than other ministers in navigating out of difficult situations mainly because of his innate abilities to be more adaptable and nuanced when dealing with difficult situations.

There is no doubt the organ trade issues are very difficult to resolve. There will be no solution that will make everyone happy. Often in this kind of situation, the 'wise' approach may be just to sit on one's hands and do nothing. But having made a commitment to move forward on this, some reasonable solution now needs to be found. Personally I am prepared to give Minister the time and space to resolve this in the most appropriate way possible.

It is however critically important that we remain vigilant and mindful of the dangers ahead. For one thing, the gap between ethical and non-ethical has become a lot more narrow than it has ever been before, and it has clearly become so much easier to drift over the line (whatever this may be). Rimbursements to payments. Residents to foreigners. This is the intrinsic danger of being on the slippery slope.

Fundamental to all of this is the strength of our ethics environment. Minister Khaw is right to point to the strength of our ethics environment. But he may perhaps have overstated the case. Our ethics environment is good but maybe not as strong as he thinks. I will post more on this issue when I have a bit more time to collect my thoughts, but I think we still have a long way to go to lay claim to having an ethics environment that is robust enough to deal with complex situations like this.

Human Organ Trade - agree or disagree?

So we are back to the Human Organ Trade debate with 2 reports in today's Straits Times. One about the Canadian-based Transplantation Society's views, and the other a reprint from the Wall Street Journal. At first glance one would be forgiven for thinking the two articles were rah-rah supporting the organ trade. certainly the headlines give that impression. One reads 'Next Step: Reward Organ Donors', and the other, 'Global Transplant Group Backs Move'.

Hmmm.... Slightly misleading, I think.

Upon closer reading the two articles are clearly disagreeing with respect to the crucial points of reimbursements and payments. The Transplantation Society makes clear their position is appropriate re-imbursements for verifiable expenses. This is totally acceptable to me. In fact, their estimated sum reimbursed in UK and Australia are relatively conservative - ~S$11,000 and S$1000 respectively. Compare this with what had been earlier floated as a balloon in Singapore - S$50,000 - $100,000. A different universe altogether.

Compare this to the other article, which essentially heartily supports going all out to get the organs. Go on, pay for the organ. Find ways to incentivize the donors. Pay the donors! Tellingly the article quotes Minister Khaw as using the phrases 'appropriate incentives' and 'reasonable payments' .

So I leave it to you to figure if the articles agree with each other, and are both similarly supportive of the organ trade.

Ultimately, Singapore, you have to decide what you want.

Madagascar Jasmine - Stephanotis floribunda

Madagascar Jasmine - Stephanotis floribunda

Easily my fav flower. The Madagascar Jasmine.

Don't see it often, but when it blooms it's heavenly. I don't get out enough to take photos, but I was lucky to have been able to take a picture of these blooms after a shower. I think it's a beautiful picture. Kinda proud of it cos it's my own pic and not something filched off somebody else's site.

Hope you like it too...

Finishing well....dying well.

While taking my usual digs at the Straits Times, I have to compliment them on the excellent series of article they did in today's papers on 'dying well'. I think they were a timely contribution, sensitively done. So congrats ST, well done!

Helping our elderly approach the end of their journey is such an important service that the community needs. Apart from just making sure they have adequate Medisave and $$ to pay for illnesses and hospitalization, the need a well constructed and compassionate set of services that will help them ensure the last years are lived out in peace and contentment. I am not just refering to social support services when they get into trouble. Rather the access to positive, pro-health services that encourage the elderly to pre-empt problems because by the time difficulties emerge, the will or ability to resolve these are at their weakest.

Why not have services to facilitate making of wills? Legal advise on resolution of difficult domestic legal issues? Social counselling services that encourage and facilitate conflict resolutions within families? Spiritual counselling for those who need? Friendship services for those who are alone or are incapacitated in some way or other?

So much food for thought.

Third Medical School - another fait accompli

While accepting that the Straits Times often function as little more than a mouth piece for the gahment, today's editorial about this issue was nonetheless surprising in its bland political correctness. I mean, was the editorial even necessary?

To my mind, Minister's comments about the third medical school was little more than the usual balloons gahment agencies float prior to making their decisions known to the public. Often decisions have already been made.... or almost entirely made. Just need the final rubber stamp. Short of there being some likelihood of a tsunami of public antipathy, the decisions usually pass and become a relatively bland news item when they are finally announced.

This is likely for the third school. There has already been much corridor talk for some time. Tan Tock Seng Hosiptal. An US big name (which won't be mentioned here) school to link up with. Emphasis on community medicine? Up and running pretty soon (couple of years, did someone say?). As I understand, things are already at a pretty mature stage of discussions.

So what's the point of my post?... A desperate attempt on behalf of the many passionate medical educators (real ones... not the hot-air pedagogists) that an appropriate consideration be given to training of doctors for our local health needs, and not be too distracted by chasing wealth, fame and glory associated with our external biomedical economy. It's not too late to try and get our priorities sorted out.

So, please sir, may we have some crumbs off the plate?

Hand Foot and Mouth Disease - What will it be for Singapore in 2009?

From MOH report

There was a convergence of 2 news items yesterday. Firstly there was a short report about a law suit between the El-Amin Education child care centre and the Straits Times; and then there was a report about the rising HFMD cases in Hong Kong/China.

This is a grim reminder of what is to come in Singapore as we move into the time of year when the HFMD epidemic hits. The chart below shows the incidence last week moving into the warning zone. I am actually quite surprised why MOH has not started its public programmes to warn the public of the impending epidemic.

In Singapore the potentially deadly EV71 virus was found in 33.2% of cases as compared to about 13% in Hong Kong. The MOH published a report about the 2008 epidemic here. I tried to find some information about mortality figures related to HFMD in Singapore but could not find anything very much. Only thing I could dredge up was that in the 2000/2001 epidemic there were 7 HFMD related deaths, out of which had EV71. At that time ~66% of samples were EV71 positive.

So what are we to expect this year? Likely the epidemic will hit in some way or other. Current figures are almost identical to last year's data. We can however, mitigate the risks by following good hygienic practices in schools especially:

• Wash hands with soap before eating and after going to the toilet;
• Cover mouth and nose when coughing or sneezing;
• Maintain good air circulation;
• Clean thoroughly toys or appliances which are contaminated by nasal or oral secretions; and
• Do not share eating utensils

Last year a number of schools were closed during the epidemic. I don't know what will happen this year. But I do know it will come with signifcant disruptions to family life. We have not found solutions to the closure of schools and child care centres. What do we do with infected children? How to quarantine them? What do we do with children whose child care centres are closed down? How do working families cope?